Burundi's 'Worst Enemy': the Country's Fight Against COVID-19

Home , 2020 in Burundi, Pierre Buyoya

Manirambona et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Kesmas: Jurnal Kesehatan Masyarakat Nasional Health Journal). 2021; 16 (Special Issue 1): 55-58. DOI: 10.21109/kesmas.v0i0.5029 (National Public Health Journal)

Burundi’s ‘Worst Enemy’: the Country’s Fight Against COVID-19

Emery Manirambona1*, Henna Reddy2, Emmanuel Uwiringiyimana1, Theogene Uwizeyimana3, Archith Kamath4 , Sai Arathi Parepalli4, Salvador Sun Ruzats5, Blaise Ntacyabukura6, Sheikh M S Islam7, Attaullah Ahmadi8, Don E Lucero-Prisno III9-10

1 2 Department of General Medicine and Surgery, College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda; Medical Sciences Division, University of Oxford, 3 4 Oxford, United Kingdom; Department of Public Health, College of Health Science, Mount Kenya University Rwanda, Kigali, Rwanda; Oxford University Global Surgery Group, 5 University of Oxford, Oxford, United Kingdom; Department of Health and Human Sciences, Faculty of Public Health, University of Huddersfield, Huddersfield, United Kingdom; 6 7 Department of Global Public Health, Karolinska Institute, Centre for Infectious Disease Institute, Stockholm, Sweden; Institute for Physical Activity and Nutrition, Deakin 8 9 University, Melbourne, Australia; Medical Research Center, Kateb University, Kabul, Afghanistan; Department of Global Health and Development, London School of Hygiene 10 and Tropical Medicine, London, United Kingdom; International Health Program, Faculty of Management and Development Studies, University of the Philippines (Open University), Los Baños, Laguna, Philippines Abstract Coronavirus disease 2019 (COVID-19) has proved to be a severe global public health threat, causing high infection rates and mortality worldwide. Burundi was not spared the adverse health outcomes of COVID-19. Although Burundi’s initial response to the COVID-19 pandemic was criticized, hope arose in June 2020 when the new government instituted a plan to slow virus transmission that included public health campaigns, international travel restrictions, and mass testing, all of which proved effective. Burundi has faced many challenges in containing the virus, the first of which was the lack of initial preparedness and appropriate response to COVID-19. This was exacerbated by factors including shortages of personal protective equipment (PPE), limited numbers of life-saving ventilators (around 12 ventilators as of April 2020), and the presence of only one COVID-19 testing center with less than ten technicians in July 2020. Moreover, as Burundi is amongst the poorest countries in the world, some citizens were unable to access necessities such as water and soap, required for compliance with government recommendations regarding hygiene. Interestingly, Burundi did not implement a nationwide lockdown, allowing mass gatherings and public services to continue as usual due to a firm belief in God’s protection. As the daily confirmed cases have tripled since December 2020, Burundi must prepare itself for the threat of a new wave. Establishing precautionary measures to contain the virus and strengthening the health surveillance system in Burundi would significantly positively impact the prevention and management of COVID-19.

Keywords: Burundi, challenges, COVID-19, health policy, strengths Introduction Efforts Coronavirus disease 2019 (COVID-19), caused by the Burundi started the fight against COVID-19 on novel coronavirus, had spread rapidly worldwide since March 18, 2020, when testing and limited preventive December 2019, when it was first detected in China. The measures were implemented by the Ministry of Public World Health Organization (WHO) declared COVID-19 Health and the Fight Against AIDS. The preventive a pandemic on March 11, 2020. African countries were measures to contain the virus included handwashing with severely affected and struggled to cope with the new chal- soap and clean or chlorinated water and avoiding physi- lenges presented by this unprecedented outbreak. The cal contact through handshakes or hug.4 Burundi landlocked country of Burundi is amongst the poorest continued to run elections and other activities in the countries in Sub-Saharan Africa and the world, with a midst of the pandemic, and the limited preventive meas- dense population of around 12 million.1 Burundi report- ures instituted under the presidency of Peter Nkurunziza ed its first two COVID-19 cases on March 31, 2020. The (who died on June 8, 2020, a few days after the elections) virus was thought to originate from Rwanda and Dubai, in response to the COVID-19 pandemic were criticized with the infected individuals testing positive on March by the global health community as downplaying the out- 30, 2020.2 As of May 24, 2021, Burundi has had 4,494 break and underestimating its risks. cumulative confirmed cases with six deaths.3 Burundi has Fortunately, the new president, who came into power made great efforts and faced significant challenges in its in June 2020, devised a new plan for instituting preven- response to COVID-19, and the authors aimed to com- tive measures and declared COVID-19 as Burundi’s ment on both these aspects in this paper critically. ‘worst enemy.’5 This act moved the narrative away from the in-action of the previous government, creating a sense of urgency and issuing a call to action.

Correspondence*: Emery Manirambona, Department of General Medicine and Received : April 24, 2021 Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Accepted : June 5, 2021 Rwanda 3286, E-mail: [email protected], Phone: +25 07 8519 3568 Published : July 31, 2021

Copyright @ 2021, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2021; 16 (Special Issue 1): 55-58.

An essential step in the fight against the novel faced challenges in coping with other epidemics, includ- coronavirus was achieved by initiating public ing measles, malaria, and cholera, as well as floods that health campaigns and mass public testing, including severely damaged the country.9,10 With a low health in- 30,000 students residing in boarding schools.6 dex score of 8.9 on the Global Health Security Index and The impact of these measures in containing the virus insufficient health infrastructure, Burundi was not ini- is indisputable. As of May 18, 2021, 302,488 tests tially well prepared to respond to the outbreak. It is not have been performed in public testing centers and surprising that cases went unreported because residents health districts. The testing campaigns covered of Burundi struggled to get tested for COVID-19 in the suspected cases, contact tracing, and international early months of the outbreak despite showing COVID- travelers. The treatment was provided in hospitals to 19-like symptoms.11 symptomatic individuals free of charge. Positive Burundi’s response to COVID-19 from March to June cases were managed in isolation rooms in public 2020 was controversial, though the outcomes could have health facilities while some asymptomatic been worse. Two presidents passed away, each of whom patients isolated themselves at home. ruled the country for at least ten years. The former pres- Interestingly, on April 20, 2021, Burundi inaugurated ident, Pierre Buyoya, died outside Burundi, with the the public health emergency operations center, coordi- cause of death officially documented as COVID-19 in- 7 nating activities and responses to health emergencies. fection.12 Of note, the cause of death of President Peter Its campaign included advice on social distancing, self- Nkurunziza, who ruled from August 2005 until his death isolation in case of symptoms, wearing masks, and hand- on June 8, 2020, was officially documented as a heart washing. Furthermore, stricter preventive measures were attack. Thus, Burundi lost two presidents during announced, including the closing of all borders. This the COVID-19 era in a matter of months. measure was the second time reinstated this year as Although the first case of COVID-19 was reported at COVID-19 cases begin to rise in some parts of Africa, the end of March 2020, no clear response plan was set in with a seven-day quarantine requirement for anyone ar- motion until June of the same year. The government was riving in the country. Finally, communicating informa- accused of not providing fact-based information on tion about the virus, such as the numbers of newly con- COVID-19.13 This led to the circulation of false rumors firmed cases and deaths and news about the state of the about the disease, contributing to widespread miscon- pandemic locally and worldwide, gained importance in ceptions about COVID-19 and creating an air of uncer- raising awareness and promoting public health through tainty and fear amongst the population. During this peri- the education of Burundi’s citizens.8 As a result, more od, healthcare workers noticed an increase in the number cases were detected and quarantined, preventing others of patients presenting with COVID-19-like symptoms. from acquiring avoidable infections (Figure 1). However, few cases were reported. This may be related to a limited testing capability, as only one testing center Challenges with less than ten technicians analyzed test samples taken COVID-19 hit Burundi when leaders were mainly 14 concerned with communal, legislative, and presidential all over the country. Similarly, many healthcare election campaigns. In addition, Burundi previously professionals faced infrastructural problems

Figure1. Progress of COVID-19 Cumulative Cases in Burundi from March 2020 to May 2021

56 Manirambona et al., Burundi’s ‘Worst Enemy’: the Country’s Fight Against COVID-19 within hospitals, such as shortages of personal protective bility for this pandemic and aim to adopt the WHO’s pre- equipment (PPE) and availability of only 12 life- ventive measures while adjusting them to an appropriate saving ventilators.11 Burundi also faced challenges to and practicable level for the country.24 Reinforcement of COVID-19 testing when case numbers were on the rise. the committee in charge of the COVID-19 pandemic re- The paucity of reagents required for the polymerase sponse at different health system levels is also needed. chain reaction (PCR)-based COVID-19-specific tests has Moreover, it is necessary to ensure the availability of lab- been a barrier to providing reliable results.15 oratories for screening, adequate PPE, and enough Furthermore, lack of cooperation with WHO trained personnel to lead pandemic preparedness initia- representatives expelled from the country after be-ng tives and form an appropriate body to monitor the imple- accused of spreading false information formed a barrier mentation of public health measures and testing.25 to a global partnership and response.9 Involving community health workers (CHWs) can be es- As Burundi is amongst the poorest countries in the sential in responding to the surge in cases. They can raise world, some of its residents were unable to access neces- awareness in their communities regarding effective re- sities such as water and soap required to comply with the sponse measures to slow the COVID-19 transmission. preventive measures.16,17 Interestingly, Burundi did not CHWs play a crucial role in ensuring clinical and com- implement a nationwide lockdown, allowing mass gath- munity care by reducing the healthcare delivery time as erings and public services to continue as usual. This un- they are present locally, contact tracing and supporting popular measure is related to the authorities’ firm belief the continuation of the health system.26 9 that God protects Burundi. Moreover, one can assume Notably, specific national public health measures that this measure was taken to preserve the country’s al- must be established. For example, social events should ready vulnerable economy and citizens, most of whom be minimized, travel into and out of the country reduced, depend on daily wages. It was estimated that 80% of the and church services and meetings be given clear guide- population relies on subsistence agriculture without any lines, including increased capacity for contact tracing any 18,19 social support. positive cases of COVID-19. Moreover, Burundi should Furthermore, some COVID-19 treatment centers embrace vaccination campaigns to ensure that the popu- were overloaded and could not admit additional patients, lation is immunized against the virus, like other African resulting in inequitable management of people who test- countries.27 Finally, it is critical to establish a country- 20 ed positive for COVID-19. Crucially, residents blame specific database regarding COVID-19 management as a local public health leaders for failing to implement strict platform for independent clinical research to provide measures to contain the virus.21 The infection rate has evidence-based information for public health policies tripled since December 2020, and COVID-19 has spread and political decision-making for further improvement in all over the country as of today. Burundi has also not yet out-break management.28 Additional global received the COVID-19 vaccine. The WHO declared considerations to support and strengthen Burundi’s Burundi ineligible for the global vaccine sharing scheme economy and health system could help devise a COVAX (COVID-19 Vaccines Global Access) and did comprehensive national response plan to tackle not provide any COVID-19 vaccine thus far.22 COVID-19 and other epidemics. In addition, instead of presenting to healthcare centers, people with COVID-19 symptoms chose traditional Conclusion “food medicines,” including ginger, lemon, and eucalyp- Burundi’s response to the COVID-19 pandemic dur- tus leaves.23 Though such traditional “food medicines” ing the first four months of the outbreak was controver- are crucial tools of cultural importance in communities’ sial. However, Burundi has made notable progress from response to health crises, their usage has public health June 2020, expressing urgency and taking significant ac- implications. It can prevent people from consulting tion against the outbreak. Furthermore, measures includ- healthcare professionals and receiving the necessary and ing public health campaigns and control of international appropriate treatment, thus contributing to higher mor- travel alongside mass testing have had a substantial pos- tality rates and the uncontrolled spread of COVID-19. itive impact. However, Burundi has to face challenges Developing an unambiguous evidence-based use of such with other preventive measures, such as the availability remedies in the prevention and treatment of COVID-19 of soap and handwashing, due to the financial limitations would greatly benefit the people who choose traditional of its citizens. The establishment of specific public health food medicines or cannot afford modern healthcare. measures will be indispensable in containing the virus.

Discussion Abbreviations Given the current situation, the government of COVID-19: Coronavirus disease 2019; WHO: World Health Burundi and public health leaders need to take responsi- Organization; COVAX: COVID-19 Vaccines Global Access; CHWs: Community Health Workers.

57 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2021; 16 (Special Issue 1): 55-58.

Ethics Approval and Consent to Participate 13. Human Rights Watch. Burundi: fear, repression in Covid-19 Not applicable. response. HRW Region Nairobi; 2020 [cited 2021 Mar 14]. 14. Agences A, Quenum F. Covid-19 au Burundi: le nouveau Competing Interest pouvoirprend le contre-pied du régime Nkurunziza. DW; 2020 [cited The authors declare no conflicts of interest. 2020 May 30]. 15. Radio Publique Africaine. Le Burundi se contenterait-il des Availability of Data and Materials raccourcispour dépister la Covid-19 ? RPA; 2021 [cited 2021 May 24]. Not applicable . 16. Misago J. Covid-19/Pénurie d’eau: certains quartiers de Gihosha entrele marteau et l’enclume. IWACU. Bujumbura, Burundi; 2021 Authors’ Contribution [cited2021 Mar 16]. EM: Conceptualization and design. HR, EM, EU, TU, AK, SAP, SSR: 17. Desmon S. COVID-19 prevention when there’s no soap and Data collection and literature review, writing- Original draft prepara- water. Johnson Hopkins Center for Communication Program; 2020. tion and visualization. AA, BN, SMSI, DELP: Supervision, writing- re- 18. La Banque Mondiale. Burundi - Vue d’ensemble; 2021. viewing, editing and proofreading. 19. Concern Worldwide. Why life is so hard in Burundi; 2017 [cited

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